Subtotal versus total parathyroidectomy: retrospective patient-centric outcomes in a chronic dialysis population

Background: Hyperparathyroidism occurs commonly in the dialysis population, and surgical parathyroidectomy (PTx) is often required when medical therapy to suppress parathyroid hormone (PTH) fails. Surgical techniques include subtotal and total PTx, with or without auto-transplantation, with the choice of procedure generally determined by surgical preference rather than patient-related factors. The aim of this study was to compare outcomes of these surgical procedures, focusing on post-operative utilization of hospital resources, and biochemical and patient-level outcomes over the year following surgery. Methods: This retrospective observational study included dialysis patients undergoing subtotal or total PTx (± auto-transplant) over 9-years at three tertiary-level hospitals in Sydney, Australia. Laboratory and patient-level-outcomes were compared immediately post-operatively and at one, three and 12-months. Results: Of 64 dialysis patients undergoing PTx, 60.9% were male and the mean dialysis vintage was 5.9 (4.2) years. Total PTx was performed in 51, 46 with auto-transplantation, and subtotal PTx in 13. Patient characteristics were similar at baseline. Compared to subtotal PTx, total PTx resulted in lower post-operative calcium values (p = 0.01), higher intravenous calcium requirements (p = 0.03) and more frequent admission to intensive care (p = 0.03). After total PTx, the daily calcium and calcitriol pill burden at discharge was higher (median 25 (IQR 20–40) vs. 18 (IQR 6–26), p = 0.04) and at 3-months (p = 0.01), and 23.5% of patients were readmitted for calcium management (p = 0.05). At 12-months, more patients undergoing subtotal PTx had PTH values above guideline recommendations (42.9% vs. 9.3%, p = 0.02), pill burdens did not differ, and bone mineral density increased in both groups. Conclusions: Total PTx requires greater post-operative resources but is associated with lower PTH values at 12-months, whereas subtotal PTx is associated with a lower pill burden but increased hyperparathyroidism recurrence. A tailored strategy is suggested, matching the surgical approach to patient needs.